Cost-effectiveness of using hepatitis C viremic hearts for transplantation into HCV-negative recipients

A Review of Heterogeneity in Comparative Economic Analysis, with Specific Considerations for the Decentralized US Setting and Patient-Centered Care

Patient-centered care emphasizes individual preferences, but insurer coverage decisions-based on population-level evidence-may restrict treatment options for patients who differ from the average. This highlights the importance of considering heterogeneity, which refers to differences in health and cost outcomes that are systematically linked to variations in factors like patient characteristics, insurer policies, and provider practices. Failing to account for heterogeneity in economic evaluations can lead to suboptimal decisions, inferior outcomes, and inefficiency. This study aimed to assess the tools and methods for addressing heterogeneity in economic evaluations, examine the extent to which, and how, heterogeneity has been addressed in US cost-utility studies, and provide insights and recommendations to promote more fuller consideration of heterogeneity in US economic evaluations. We reviewed and adapted a seminal taxonomy of heterogeneity to the US setting, highlighting key drivers like patient preferences and insurance design. Methods for addressing heterogeneity in economic evaluations were also reviewed and summarized. We used data from the Tufts Medical Center Cost-Effectiveness Analysis Registry to assess empirical practices in US cost-utility applications, specifically the frequency, types, and impact of a subgroup analysis, and whether rationales for including or excluding subgroups were provided. The revised taxonomy highlights key drivers of heterogeneity in the diverse and decentralized US healthcare ecosystem, such as the diversity of patient preferences and in non-patient factors like access to healthcare providers and insurance coverage. Methods to explore, confirm, and incorporate heterogeneity into a comparative economic analysis exist, but are often challenged by data availability. In addition to the trade-off between potential efficiency gains and increasing uncertainty in comparative value estimates, ethical implications of stratified decisions were highlighted in the literature. We found that a subgroup analysis was rare, and primarily performed for clinical factors like age and disease severity. Only 2 of the 85 studies published between 2015 and 2022 with subgroup-level results were found to consider non-patient factors, and none considered preferences. One-third of studies reported incremental cost-effectiveness ratios differing by more than 50% from the unstratified estimate. No studies provided a rationale for omitting a subgroup analysis, and only two motivated inclusion of a subgroup analysis, limiting our ability to assess the appropriateness of these decisions. Despite well-documented methods to address heterogeneity, its application is limited in US cost-utility studies, especially regarding patient preferences and non-patient factors. As these factors often drive real-world health outcomes and costs in the USA, proper consideration of, and reporting on, heterogeneity is essential to avoid erroneous market access decisions, suboptimal patient outcomes, and economic inefficiency. Future efforts, including work by an upcoming Professional Society of Pharmacoeconomics and Outcomes Research Task Force, should continue to refine taxonomies and emphasize the importance of addressing heterogeneity.

For your consideration: Benefits of listing as willing to consider heart offers from donors with hepatitis C

BACKGROUND

Despite excellent outcomes of heart transplants from hepatitis C virus (HCV)-positive donors (D+), many candidates are not listed to even consider HCV D+ offers.

METHODS

Using the Scientific Registry of Transplant Recipients, we identified adult (age ≥18 years) heart transplant candidates prevalent on the waitlist between 2018 and March 2023. We compared the likelihood of waitlist mortality or heart transplant by candidate willingness to consider HCV D+ offers using competing risk regression.

RESULTS

We identified 19,415 heart transplant candidates, 68.9% of whom were willing to consider HCV D+ offers. Candidates willing to consider HCV D+ offers had a 37% lower risk of waitlist mortality (subhazard ratio [SHR], 0.63; 95% confidence interval [CI], 0.56-0.70; P < .001) than candidates not willing to consider HCV D+ offers, after adjustment for covariates and center-level clustering. Over the same period, heart transplant candidates willing to consider HCV D+ offers had a 21% higher likelihood of receiving a transplant (SHR, 1.21; 95% CI, 1.7-1.26; P < .001). As a result, among candidates willing to consider HCV D+ offers, 74.9% received a transplant and 6.1% died/deteriorated after 3 years, compared to 68.3% and 9.1%, respectively, of candidates not willing to consider HCV D+ offers. Lower waitlist mortality also was observed on subgroup analyses of candidates on temporary and durable mechanical circulatory support.

CONCLUSIONS

Willingness to consider HCV D+ heart offers was associated with a 37% lower risk of waitlist mortality and a 21% higher likelihood of receiving a transplant. We urge providers to encourage candidates to list as being willing to consider offers from donors with hepatitis C to optimize their waitlist outcomes and access to transplantation.

Breaking barriers: successful outcomes of hepatitis C virus D+/R- Transplants in HIV+ Recipients

Transplantation from donors with hepatitis C virus (HCV) viremia to recipients without HCV-viremia (HCV D+/R-) is common, but no data exist for recipients with HIV or donors with HCV/HIV coinfection. We assessed outcomes of HCV D+/R- transplants within 3 HIV Organ Policy Equity Act studies of HIV+ abdominal transplantation to recipients with HIV between 2017 and 2023. Eighteen kidney and 6 liver transplant recipients with HIV received organs from 19 donors with HCV viremia, including 7 with HCV/HIV coinfection. Median recipient age was 58 years, 96% were male, and median waitlist time was 1 year. All recipients had undetectable HIV RNA at time of transplant with median cluster of differentiation 4 count 499 cells/mm3. HCV/HIV-coinfected donors had median cluster of differentiation 4 count 210 cells/mm3, and 4 of the 7 had detectable HIV RNA. HCV treatment with direct-acting antivirals was initiated at median 33 days after transplant and sustained virologic response was achieved in 23 of the 23 treated recipients without HCV-related adverse events; data unavailable for 1 participant. Kaplan-Meier survival analysis demonstrated 100% 1-year and 96% 3-year survival. Graft survival was 96% at 1 and 3 years. HCV D+/R- abdominal transplantation, including donors with HCV/HIV coinfection, demonstrates favorable patient and graft survival in recipients with HIV and is a viable strategy to increase organ utilization.

Center and Individual Willingness to Consider Heart and Lung Offers From Donors With Hepatitis C

INTRODUCTION

Transplants with hearts and lungs from donors with hepatitis C virus (HCV D+) have been proven safe and effective since development of direct-acting antivirals, yet the presence of HCV + persists as a reason to decline organs.

METHODS

We identified adult candidates listed January 1, 2015-March 8, 2023 for heart or lung transplant using the Scientific Registry of Transplant Recipients. We identified individual-level and center-level characteristics associated with listing to consider HCV D+ offers using multilevel logistic regression in a multivariable framework.

RESULTS

Over the study period, the annual percentage of candidates willing to consider HCV D+ offers increased for both heart (9.5%-74.3%) and lung (7.8%-59.5%), as did the percentage of centers listing candidates for HCV D+ heart (52.9%-91.1%) and lung (32.8%-82.8%) offers. Candidates at centers with more experience with HCV D+ transplants were more likely to consider HCV D+ organ offers. After adjustment, listing center explained 70% and 78% of the residual variance in willingness to consider HCV D+ hearts and lungs, respectively.

CONCLUSIONS

Although listing for consideration of HCV D+ offers has increased, it varies by transplant center. Center-level barriers to consideration of HCV D+ organs reduce recipients' transplant access.

Quality-adjusted life years and surgical waiting list: Systematic review of the literature

BACKGROUND

The quality-adjusted life year (QALY) is a metric that is increasingly used today in the field of health economics to evaluate the value of different medical treatments and procedures. Surgical waiting lists (SWLs) represent a pressing problem in public healthcare. The QALY measure has rarely been used in the context of surgery. It would be interesting to know how many QALYs are lost by patients on SWLs.

AIM

To investigate the relationship between QALYs and SWLs in a systematic review of the scientific literature.

METHODS

The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. An unlimited search was carried out in PubMed, updated on January 19, 2024. Data on the following variables were investigated and analyzed: Specialty, country of study, procedure under study, scale used to measure QALYs, the use of a theoretical or real-life model, objectives of the study and items measured, the economic value assigned to the QALY in the country in question, and the results and conclusions published.

RESULTS

Forty-eight articles were selected for the study. No data were found regarding QALYs lost on SWLs. The specialties in which QALYs were studied the most in relation to the waiting list were urology and general surgery, with 15 articles each. The country in which the most studies of QALYs were carried out was the United States (n = 21), followed by the United Kingdom (n = 9) and Canada (n = 7). The most studied procedure was organ transplantation (n = 39), including 15 kidney, 14 liver, 5 heart, 4 lung, and 1 intestinal. Arthroplasty (n = 4), cataract surgery (n = 2), bariatric surgery (n = 1), mosaicplasty (n = 1), and septoplasty (n = 1) completed the surgical interventions included. Thirty-nine of the models used were theoretical (the most frequently applied being the Markov model, n = 34), and nine were real-life. The survey used to measure quality of life in 11 articles was the European Quality of Life-5 dimensions, but in 32 articles the survey was not specified. The willingness-to-pay per QALY gained ranged from $100000 in the United States to €20000 in Spain.

CONCLUSION

The relationship between QALYs and SWLs has only rarely been studied in the literature. The rate of QALYs lost on SWLs has not been determined. Future research is warranted to address this issue.

Hepatitis C and heart transplantation: An update

There are limited data regarding heart transplantation in the setting of hepatitis C virus (HCV) infection in either recipients or donors, as the practice was infrequent, given concerns of worse post-transplant outcomes. This changed dramatically after the development of highly effective HCV therapies, namely direct-acting antivirals (DAAs). Additionally, nucleic acid testing currently in use establishes more precisely the risk of HCV transmission from donors. As a result, chronic HCV infection in itself is no longer a barrier for heart transplant candidates, and the use of HCV-positive organs for HCV-infected and non-infected transplant candidates has increased dramatically. A review of the literature revealed that in the pre-DAA era, HCV seropositive heart transplant patients had a higher mortality than their seronegative counterparts. However, short-term data suggest that the differences in survival have been erased in the DAA era. Heart transplantation from HCV-viremic donors to HCV-uninfected recipients has become increasingly common as the number of deceased donors with HCV viremia has increased over the past years. Preliminary outcome reports are very encouraging, although further data are needed with regard to long-term safety. New information continues to be incorporated to optimize protocols that guide this practice.

The Cost-effectiveness of Transplanting Hearts From Hepatitis C-infected Donors Into Uninfected Recipients

BACKGROUND

The DONATE HCV trial demonstrated the safety and efficacy of transplanting hearts from hepatitis C viremic (HCV+) donors. In this report, we examine the cost-effectiveness and impact of universal HCV+ heart donor eligibility in the United States on transplant waitlist time and life expectancy.

METHODS

We developed a microsimulation model to compare 2 waitlist strategies for heart transplant candidates in 2018: (1) status quo (SQ) and (2) SQ plus HCV+ donors (SQ + HCV). From the DONATE HCV trial and published national datasets, we modeled mean age (53 years), male sex (75%), probabilities of waitlist mortality (0.01-0.10/month) and transplant (0.03-0.21/month) stratified by medical urgency, and posttransplant mortality (0.003-0.052/month). We assumed a 23% increase in transplant volume with SQ + HCV compared with SQ. Costs (2018 United States dollar) included waitlist care ($2200-190 000/month), transplant ($213 400), 4-wk HCV treatment ($26 000), and posttransplant care ($2500-11 300/month). We projected waitlist time, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs [$/QALY, discounted 3%/year]; threshold ≤$100 000/QALY).

RESULTS

Compared with SQ, SQ + HCV decreased waitlist time from 8.7 to 6.7 months, increased undiscounted life expectancy from 8.9 to 9.2 QALYs, and increased discounted lifetime costs from $671 400/person to $690 000/person. Four-week HCV treatment comprised 0.5% of lifetime costs. The ICER of SQ + HCV compared with SQ was $74 100/QALY and remained ≤$100 000/QALY with up to 30% increases in transplant and posttransplant costs.

CONCLUSIONS

Transplanting hearts from HCV-infected donors could decrease waitlist times, increase life expectancy, and be cost-effective. These findings were robust within the context of current high HCV treatment costs.

Donor Utilization in the Recent Era: Effect of Sex, Drugs, and Increased Risk

Background:

Heart transplantation volumes have increased in recent years, yet less than a third of donors are typically accepted for transplantation. Whether donor sex, donor drug use, or perception of increased risk affects utilization for transplantation is unclear.

Methods:

The United Network for Organ Sharing database was queried for donors from January 1, 2007, to December 31, 2017. Donor toxicology was collected when available. Multivariate analysis was conducted to examine correlations with donor utilization.

Results:

Between January 1, 2007, and December 31, 2017, there were 87 816 heart donors aged ≥15 years. The mean age was 42.7±15.8 years, and 24 831 donors (28.3%) were utilized for heart transplantation. Subsequent analyses focused on donors between 15 and 39 years old.

The strongest associations with donor acceptance were for male donor sex, blood type, hepatitis C antibody, donor age, left ventricular hypertrophy, and history of donor drug use. After removing hepatitis C, Public Health Service Increased Risk was identified as a strong negative predictor. Most positive drug toxicology results were associated with donor nonuse except for donors between 15 and 19 years of age. Exceptions included alcohol, marijuana, and cocaine. Opiates were associated with less utilization at all donor ages. The Public Health Service Increased Risk status was associated with significantly less utilization in all age groups except 15- to 19-year-old donors.

Conclusions:

While male donors were preferentially utilized, donors with drug use or those deemed Public Health Service Increased Risk were significantly less utilized for heart transplantation. Further consideration of such donors would be appropriate particularly as the demand for transplantation continues to increase.

Hepatitis C Positive Organ Donation in Heart Transplantation

Purpose of Review

To summarize outcomes to date, as well as important considerations and unanswered questions related to the use of hepatitis C virus (HCV) positive donors for heart transplantation.

Recent Findings

Outcomes from single-center studies and registry data to date suggest that among patients who develop donor-transmitted HCV after heart transplantation, direct-acting antiviral therapies (DAAT) are effective and well-tolerated, and that short-term survival is similar to that of patients transplanted with HCV - donors.

Summary

In an era marked by increasing numbers of HCV positive deceased donors and a growing imbalance between the demand and supply of donor hearts, utilization of HCV + donors is a feasible strategy to expand the donor pool and reduce waitlist times. Ongoing work is needed to clarify longer-term outcomes with the use of this strategy.

Effect of Hepatitis C donor status on heart transplantation outcomes in the United States

BACKGROUND

Recent studies demonstrated safety and efficacy of heart transplantation (HT) from hepatitis C virus (HCV)-positive donors. We sought to evaluate the impact of HCV donor status on the outcomes of patients undergoing HT in the United States.

METHODS

We analyzed a retrospective cohort of adult patients from the United Network for Organ Sharing (UNOS) database who underwent isolated HT from 2015 until present. Primary outcomes were 30-day and 1-year overall mortality. Secondary outcomes included risk for graft failure and overall survival, incident stroke and need for dialysis during the available follow-up period. All end points were evaluated according to HCV status.

RESULTS

All-cause 30-day and 1-year mortality was similar between the two groups (3.4% vs 3.2%, P = .973 and 6.9% vs 7.8%, P = .769, respectively, for patients receiving heart grafts from HCV+ vs. HCV- donors). Graft failure was 12.8% (95% CI: 8%-19%) and 15.2% (95 CI: 15%-16%) in the HCV+ and HCV- groups, respectively (P = .92 and P = .68). Competing risk regression analysis for re-operation showed a non-significant trend for higher risk for re-transplantation in the HCV+ group (HR: 2.71; 95% CI: 0.83, 8.80, P = .097).

CONCLUSION

HCV donor status does not seem to negatively affect the outcomes of HT in the U.S population.